Legal Aid of Manasota
Incorporated Nonprofit Application

Community Counsel Program

Please fill out the form below to apply.

Corporation Information
Name of Corporation
State of Incorporation
Year Incorporated
Address
City/Zip
/
Phone
Fax
E-Mail

Corporation Contacts
Primary Contact
Primary Contact Phone
Primary Contact Address
Primary Contact Position/Office
Primary Contact E-Mail
Secondary Contact
Secondary Contact Phone
Secondary Contact Address
Secondary Contact Position/Office
Secondary Contact E-Mail

Purpose of Corporation

Geographic Target Area
Geographical Area
County

Will this Corporation primarily serve low-income people?
Yes, this Corporation primarily serves low-income.
No, this Corporation does not primarily serve low-income.

Is the Corporation financially able to retain and pay for a private attorney?
Yes, this Corporation is able.
No, this Corporation is not able.

Does the Corporation have any board members who are attorneys?
Yes, this Corporation does have an attorney on the board.
No, this Corporation does not have an attorney on the board.

If yes, please enter list.

Has the Corporation retained and paid an attorney in the past 12 months?
Yes, this Corporation has retained an attorney.
No, this Corporation has not retained an attorney.

If yes, please enter list.

Approximate number of clients the Corporation serves annually:

General Statement of legal problem

What was the Gross receipts of the Corporation last fiscal year?

How did you learn about the Community Counsel project?

I hereby certify that the above information is correct.
Signature

Office/Title

Date (MM-DD-YYYY)